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Your name *

Phone number *

Alternative phone number *

Address *

City *

State *

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Zip *

Person(s) discriminated against (if different than the preparer of this form)

Address

City

State

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

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I believe that I (or the person(s) listed above) has been discriminated against on the basis of:

Race

Sex

Color

Disability

National Origin (Limited English Proficiency)

Economic Status

Description of incident

Please describe the alleged discrimination incident. Providethe names and titles of all LANTA employees involved, if available. Explain what happened and whom you believe was responsible.

Date of Incident

Have you filed this complaint with any other federal, state, or local agency?

Yes

No

If yes, Agency Name

Agency Contact Name

Agency Street Address

Agency City

Agency State

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Agency Zip

I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.

Name *

Date *

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